The Trichotillomania is a condition characterized by recurrent impulse to tear hair or hairs, by repeated attempts to reduce or suspend the tear and a significant distress or malfunction working, social and interpersonal due to the symptom.
The phenomenology of the disorder appears very simple, but recent research has highlighted behavioral and symptomatic heterogeneity.
The pulling behavior , for example, can be carried out with the fingers, tweezers or other cosmetic techniques, pulling one or two hairs or hair at a time and the areas most frequently torn are the scalp, eyebrows, eyelashes and the pubis.
The pulling is often preceded by ritualistic behaviors such as combing the hair, feeling the single hair between the fingers, pulling it and visually investigating the area. Hair or hair is not plucked at random, but is often chosen based on tactile or visual characteristics.
Post-tearing behaviors are also clinically relevant, and while some simply throw away their torn hair, others ball it up in their fingers, inspect it, bite the hair, or go as far as ingesting it (known as ringworm).
The subject of investigation is also the environmental and emotional context within which the tear-off behavior occurs.
Situational variables that can fuel the impulse are usually sedentary situations, such as watching TV, reading a book or preparing in front of the mirror.
Recent studies have also distinguished various styles of trichotillomania , which can correspond to different triggers. Two styles of tearing have been identified, automatic and conscious.
The automatic pulling is done unconsciously, often during moments of sedentary lifestyle, and does not become aware until the consequences are noticed (for example, a bunch of balled up hair).
On the contrary, conscious pulling seems to be a process aimed at various purposes, such as the pleasure deriving from the tear, to reduce negative emotions, to remove hair that seems out of place or that has certain characteristics.
Some research shows us that conscious jerking could be an attempt to regulate negative emotions or thoughts.
Precisely due to the great heterogeneity of this symptomatological condition it is advisable to pay close attention to the diagnosis.
The repetitive characteristics of the behavior and the position within the DSM-5 can confuse this condition with Obsessive Compulsive Disorder .
However they are phenomenologically very different from each other, first of all for the pleasure derived from the tearing behavior, absent in the performance of compulsive rituals, furthermore for the absence of both intrusive thoughts and the multiplicity of ritualistic behaviors, even very different from each other, that we can find in Obsessive Compulsive Disorder .
Another characteristic to be taken into consideration during the assessment is the presence of shame and dissatisfaction with one’s appearance, which could lead back to the Dysmorphophobic Disorder which, however, leads to focusing one’s attention and possible tearing only in order to correct an alleged cosmetic defect. Finally, some suggest similarities with those disorders involving emotional regulation and self-injurious behaviors.
In Borderline disorder , for example, tearing or self-injurious behaviors can regulate the emotional state, but are expressly aimed at feeling pain, while in trichotillomania this intentionality is not present.
However, it is known that patients with trichotillomania often report a reduction in anxiety, tension and boredom after tearing episodes.
A psychological factor that can mediate the relationship between tear and emotions was found in the concept of psychological inflexibility, conceptualized in ACT (Acceptance and Commitment Therapy), which is identified in a set of generalized and maladaptive strategies to regulate disturbing emotions and thoughts. unwanted. Various studies show that psychological inflexibility plays a role in controlling maladaptive behaviors aroused by negative emotions and cognitions.
Attempting to control disturbing internal experiences facilitates tearing behavior, which functions as a positive reinforcement, initially in which it mitigates the disturbing emotion, subsequently generating negative emotions and thoughts about oneself and triggering the vicious cycle that can maintain this disorder.
This conceptualization of the disorder can reinforce the therapeutic strategies available to cognitive-behavioral therapy .
Empirical evidence has already shown a good efficacy of some techniques, such as Habit Reversal Training and stimulus control interventions, successfully used for the management of repetitive behaviors, as well as cognitive techniques for identifying dysfunctional thoughts.
These interventions have shown excellent effectiveness in the management of tearing behavior and in learning alternative and more adaptive behaviors, favoring the awareness of automatic thoughts that can precede the tearing in order to adequately cope with the situation.
However, research shows us that there remains a significant percentage of patients who, despite having learned good behavioral management strategies, remain partially disturbed by the emotional experiences that, as we have seen, in some cases act as triggers for behavior.
In these cases we are met by the Dialectical Behavior Therapy (DBT) and the Acceptance and Commitment Therap y (ACT) which have shown excellent efficacy in learning new emotional management strategies.
DBT facilitates awareness of emotions such as anger, boredom, and frustration by addressing maladaptive emotional regulation strategies that reinforce and maintain jerking behavior and replacing them with new and more adaptive regulatory abilities.
Thanks to mindfulness exercises, emotional and cognitive awareness is trained and the level of reactivity to disturbing emotions is reduced.
ACT starts from the assumption that tearing behavior originates from “experiential avoidance”, that is, from the unwillingness to experience certain emotional states. Through experiential exercises and the learning of mindfulness skills the ACT emphasizes the concept that the problem lies not in the impulse to tear within oneself, but in the reaction to the impulse and the struggle that the person engages with his or her disturbing emotional experiences.
Still in the context of cognitive-behavioral therapeutic approaches , ACT techniques, together with DBT techniques, can broaden the range of therapeutic action, helping the patient to develop a different vision of their own internal experiences, obviating the need to avoid them, making the system more flexible. and directing it towards acceptance, mindfulness skills and committed action towards functional areas of life.